What makes a difference to patients?

Abstract

To make a difference to patients who increasingly suffer multiple chronic conditions, in a healthcare system that is capable of providing excellent care but is often ineffective and at cross-purposes in its application, means being prepared to take a different approach not only to the delivery of patient care, but to the education of physicians and other healthcare professionals. The model we must now practice and teach is one that emphasizes collaboration and prevention, quality and efficiency. Changes in practice recommended by the 2001 US Institute of Medicine report are being implemented system-wide, following the enactment of the US Patient Protection and Affordable Care Act. This paper discusses the evolving needs of patients with chronic psychiatric illness, and the psychiatrist's role in a rapidly changing healthcare landscape as a care provider, an interdisciplinary role model, and educator. In an aging population in which multi-morbidity is the norm, episodic, crisis-driven care is prohibitively expensive and does not serve patients well. Yet we still teach that model of care. The medications we prescribe for psychiatric illness, particularly antipsychotics, can cause and/or aggravate some of the commonest chronic medical illnesses; psychiatric educators must address the management of these complications. The management of chronic psychiatric illness in multi-morbid patients demands that we practice and teach a ‘whole patient’ approach to care, preferably delivered as part of a patient-centred team. The Affordable Care Act has mandated and created opportunities for new models designed to facilitate this, and a paradigm shift is needed in medical education. Clinicians must become adept at identifying underlying and contributing factors and collaborating with the patient, other providers, and the patient's family and significant others. Psychiatric formulation and patient care rely on these principles; we must now teach their application to other specialties, disciplines and professions.     

What makes a mental ill violent?

From numerous tests it is clearly to be concluded that between severe mental health problems and the act of violence exists a moderate, but reliable association. With this conclusion, neither old fears of "an unpredictable insane person" should be reactivated nor stigmatisation are to be carried out. Particularly since the whole of humans with psychological disturbances does not exhibit an increased act of violence risk in relation to the average population. It is however necessary to identify subgroups with increased tendency for self- and other aggressive behaviour, to describe aggression-aroused and reducing factors and to appreciate the positive influence of the psychiatric therapy and the social rehabilitation. After today's level of knowledge it is to be proceeded from the following risk indicators: Diagnosis of a paranoid disturbance, male sex, correlation with personality disorder and substance abuse, lack of treatment, increasing social disintegration with a longer treatment process and uncertain competence for the support. Extensive psychiatric treatments reduce the risk clearly. The deinstitutionalisation does not have negative influence with secured ambulatory support. The legal accommodation framework, which is discussed on the basis of the Austrian law situation, is an important modifying factor. Relating to the mental health problem there is just a little relation to the aggressive behaviour in comparison to the average population.     

What makes a drug a primary mood stabilizer?

The term 'mood stabilizer' has been applied to a number of medications for the treatment of patients with bipolar disorder. The operational definition of the properties of a mood-stabilizing medication has varied according to the properties of specific medications and the clinical characteristics of the illness. Randomized controlled trials of agents accepted or proposed as mood stabilizers are reviewed to marshall the available evidence in support of this claim. In addition, potential pharmacological mechanisms underlying mood-stabilizing effects of established compounds are reviewed.     

What makes something psychoanalytic?

QUESTIONS about the "essence" or boundary of a subject matter are both useful and hazardous. These concerns can coalesce or divide, divert or focus, affirm or degrade. With the hazards in mind, I wish to identify the forms of activity specific to psychoanalysis and psychoanalysts apart from other disciplines and practitioners. Given the variety of practices and the competing and complimentary theories, psychoanalysts have grown uncertain and defensive about the special domain of their inquiry. What makes something psychoanalytic?     

A few thoughts on “What is a seizure?”

This article is part of a Supplementary Special Issue entitled The Future of Automated Seizure Detection and Prediction.     

Can a generalized kindling seizure induce a reward state?

The postictal behavioral depression (PBD), characterized by behavioral immobility and unresponsiveness to environmental stimuli, observed after a stage 5 kindling seizure is opioid dependent. Morphine injection prolongs while naloxone and naltrexone (opioid antagonists) reduce or eliminate PBD. Opioids have clear rewarding actions that can be easily detected by place preference conditioning (PPC). In the present study, we evaluated if the opioid release after a stage 5 kindling seizure that produces PBD could induce PPC. Male rats were kindled in the medial preoptic area (MPOA), the amygdala (AMG) or insular cortex (IC). After kindling was established their initial preference in a three-compartment chamber was determined. During conditioning, subjects received a standard kindling stimuli that evoked a stage 5 seizure. At the end of the after discharge and during the PBD the animals were placed in the non-preferred chamber for 30 min. On alternate days they were placed without stimulation in the preferred chamber. At the end of conditioning the kindled groups showed a clear change of preference. This change of preference was completely blocked by injection of naloxone. These results suggest that opioid release after a stage 5 kindling seizure can induce a positive affect of sufficient intensity and duration to induce conditioning.     

Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure

Purpose:   To compare mortality and subsequent unprovoked seizure risk in a population-based study of acute symptomatic seizure and first unprovoked seizure due to static brain lesions.
Methods:   We ascertained all first episodes of acute symptomatic seizure and unprovoked seizure due to central nervous system (CNS) infection, stroke, and traumatic brain injury (TBI). Subjects were residents of Rochester, Minnesota, identified through the Rochester Epidemiology Project's records-linkage system between 1/1/55 and 12/31/84. Information was collected on age, gender, seizure type, etiology, status epilepticus (SE), 30-day and 10-year mortality, and subsequent episodes of unprovoked seizure.
Results:   Two hundred sixty-two individuals experienced a first acute symptomatic seizure and 148 individuals experienced a first unprovoked seizure, all due to static brain lesions. Individuals with a first acute symptomatic seizure were 8.9 times more likely to die within 30 days compared to those with a first unprovoked seizure [95% confidence intervals (CI) = 3.5–22.5] after adjustment for age, gender, and SE. Among 30-day survivors, the risk of 10-year mortality did not differ. Over the 10-year period, individuals with a first acute symptomatic seizure were 80% less likely to experience a subsequent unprovoked seizure compared with individuals with a first unprovoked seizure [adjusted rate ratio (RR) = 0.2, 95% CI = 0.2–0.4].
Discussion:   The prognosis of first acute symptomatic seizures differs from that of first unprovoked seizure when the etiology is stroke, TBI, and CNS infection. Acute symptomatic seizures have a higher early mortality and a lower risk for subsequent unprovoked seizure. These differences argue against the inclusion of acute symptomatic seizures as epilepsy.     

What happens now? Ongoing outcome after post-temporal lobectomy seizure recurrence

We studied outcome subsequent to the initial post-temporal lobectomy seizure recurrence (n = 202) or remission. Two years after recurrence, there was 74% (95% CI 67% to 79%) probability of further seizures. Two years after a 2-year seizure remission, there was 68% (95% CI 52% to 79%) probability of remaining seizure-free (n = 50). Remission after seizures had a significantly poorer outcome than an equivalent period of complete seizure freedom after surgery. Implications for outcome classification are discussed.     

Concussive convulsions: seizure or no seizure?

Convulsions following traumatic brain injury (TBI) represent a diagnostic and therapeutic challenge. They can be differentiated into late (> 7 days after TBI), early (1 - 7 days after TBI), immediate (within the first 24 h after TBI), and impact seizures (within seconds after TBI). Some authors suggest that most impact seizures are non-epileptic in origin and hence coined the term "concussive convulsions" for benign impact seizures. Early and late post-traumatic seizures frequently indicate structural brain damage and transition to chronic, post-traumatic epilepsy. The data for impact seizures or concussive convulsions is less clear: only a small percentage of impact seizures is associated with structural brain damage and the development of post-traumatic epilepsy, rather the majority of cases are benign and associated with an excellent prognosis. Here, we present a case report as a starting point for pathophysiological and clinical considerations regarding convulsions that start within seconds after TBI.     

What actually makes bullying stop? Reports from former victims

School bullying is a serious, worldwide problem which is not easily counteracted. The present study focuses on the perspective of former victims, asking them what it was that made the bullying stop in their case. Participants were 273 18-year-old former victims in Sweden, a country in which schools are doing extensive work against bullying and the bullying prevalence is relatively low. Results showed that although support from school personnel was the most common reason that the former victims gave to why the bullying had ended, it was only mentioned by a fourth of them. In fact, it was almost equally as common that the bullying had ended in that the victims transitioned to a new school level or changed their way of coping with the bullying. Very few of the adolescents reported that the bullying had stopped due to support from peers.